BNF for Children 2011-2012

372 6.3.2 Glucocorticoid therapy BNFC 2011–20126 Endocrine systemTopical, inhaled or rectal corticosteroids are less likelyto be associated with an increased risk of severechickenpox.Measles Children taking corticosteroids, and theircarers, should be advised to take particular care toavoid exposure to measles and to seek urgent medicaladvice if exposure occurs. Prophylaxis with intramuscularnormal immunoglobulin (section 14.5.1) may beneeded.Withdrawal of corticosteroidsThe magnitude and speed of dose reduction in corticosteroidwithdrawal should be determined on a case-bycasebasis, taking into consideration the underlyingcondition that is being treated, and individual patientfactors such as the likelihood of relapse and the durationof corticosteroid treatment. Gradual withdrawal of systemiccorticosteroids should be considered in thosewhose disease is unlikely to relapse and have:. received more than 40 mg prednisolone (or equivalent)daily for more than 1 week or 2 mg/kg daily for1 week or 1 mg/kg daily for 1 month;. been given repeat doses in the evening;. received more than 3 weeks’ treatment;. recently received repeated courses (particularly iftaken for longer than 3 weeks);. taken a short course within 1 year of stopping longtermtherapy;. other possible causes of adrenal suppression.Systemic corticosteroids may be stopped abruptly inthose whose disease is unlikely to relapse and who havereceived treatment for 3 weeks or less and who are notincluded in the patient groups described above.During corticosteroid withdrawal the dose may bereduced rapidly down to physiological doses (equivalentto prednisolone 2–2.5 mg/m 2 daily) and then reducedmore slowly. Assessment of the disease may be neededduring withdrawal to ensure that relapse does not occur.Psychiatric reactionsSystemic corticosteroids, particularly in high doses, arelinked to psychiatric reactions including euphoria, nightmares,insomnia, irritability, mood lability, suicidalthoughts, psychotic reactions, and behavioural disturbances.A serious paranoid state or depression with riskof suicide can be induced, particularly in children with ahistory of mental disorder. These reactions frequentlysubside on reducing the dose or discontinuing thecorticosteroid but they may also require specific management.Children and their carers should be advised toseek medical advice if psychiatric symptoms (especiallydepression and suicidal thoughts) occur and they shouldalso be alert to the rare possibility of such reactionsduring withdrawal of corticosteroid treatment.Systemic corticosteroids should be prescribed with carein those predisposed to psychiatric reactions, includingthose who have previously suffered corticosteroidinducedpsychosis, or who have a personal or familyhistory of psychiatric disorders.Advice to children and carersA patient information leaflet should be supplied toevery patient when a systemic corticosteroid isprescribed. Children and carers should especiallybe advised of the following (for details, see Infections,Adrenal Suppression, and Psychiatric Reactionsabove and Withdrawal of Corticosteroidsbelow):. Immunosupression Prolonged courses of corticosteroidscan increase susceptibility to infectionand serious infections can go unrecognised.Unless already immune, children are at risk ofsevere chickenpox and should avoid close contactwith people who have chickenpox or shingles.Similarly, precautions should also be takenagainst contracting measles;. Adrenal suppression If the corticosteroid isgiven for longer than 3 weeks, treatment mustnot be stopped abruptly. Adrenal suppressioncan last for a year or more after stopping treatmentand the child or carer must mention thecourse of corticosteroid when receiving treatmentfor any illness or injury;. Mood and behaviour changes Corticosteroidtreatment, especially with high doses, can altermood and behaviour early in treatment—thechild can become confused, irritable and sufferfrom delusion and suicidal thoughts. Theseeffects can also occur when corticosteroid treatmentis being withdrawn. Medical advice shouldbe sought if worrying psychological changesoccur;. Other serious effects Serious gastro-intestinal,musculoskeletal, and ophthalmic effects whichrequire medical help can also occur; for detailssee Side-effects of Corticosteroids, p. 373.Steroid treatment cards (see p. 373) should be issuedwhere appropriate. Doctors and pharmacists canobtain supplies of the card from:England and Wales3M Security Printing and Systems LimitedGorse Street, ChaddertonOldham, OL9 9QHTel: (0161) 683 2189Fax: (0161) 683 2188nhsforms@spsl.uk.comScotlandR.R. Donnelley Global Document Solutions20–22 South Gyle CrescentEdinburgh, EH12 9EBTel: (0131) 334 1229Fax: (0131) 334 5946ian.fruish@rrd.comNorthern IrelandPharmaceutical DirectorateBusiness Services Organisation2 Franklin StreetBelfast, BT2 8DQTel: (028) 9053 5652Other cautions and contra-indicationsOther cautions include: growth restriction—possiblyirreversible, frequent monitoring required if history of